轉(zhuǎn)移背闊肌肌皮瓣修復(fù)術(shù)在局部晚期乳腺癌手術(shù)中的應(yīng)用,.,Contents,局部晚期乳腺癌定義,局部晚期乳腺癌治療現(xiàn)狀,背闊肌解剖學(xué),背闊肌肌皮瓣修復(fù)術(shù)手術(shù)要點(diǎn),注意事項(xiàng)及臨床體會(huì),.,局部晚期乳腺癌治療現(xiàn)狀？,.,Impact of progression during neoadjuvant chemotherapy on surgical management of breast cancer.,METHODS: We reviewed clinicopathological data on patients who received NCT for stage I-III breast cancer from 1994 to 2007. Chemotherapy regimens were anthracycline-and/or taxane-based as determined by the treating medical oncologist. RESULTS: Of 1,928 patients who received NCT, 1,762 (91%) had a partial or complete response, 107 (6%) had stable disease (SD), and 59 (3%) progressed (PD) while receiving at least one regimen. Of the patients with progressive disease, 40 (68%) patients underwent mastectomy, 12 (20%) underwent BCT, and 7 (12%) did not undergo surgery. In patients who underwent mastectomy, only three (8%) were BCT candidates before progression. Overall, disease progression changed the operative plan in 11 (0.5%) patients: 3 developed distant metastasis, 2 developed clinical lymphadenopathy, 3 required mastectomy instead of BCT, 2 became inoperable, and 1 required flap closure.CONCLUSIONS: Disease progression while receiving NCT is infrequent (3%), but early identification may allow for change to other, potentially beneficial, therapeutic interventions. Patients with breast cancer who receive NCT should be evaluated frequently for response to therapy. Overall, progression during NCT changes the surgical management in a small proportion of patients.,Caudle AS et al. Ann Surg Oncol. 2011 Apr;18(4):932-8.,.,轉(zhuǎn)移背闊肌肌皮瓣修復(fù)術(shù)適應(yīng)癥及禁忌癥,適應(yīng)癥：乳房切除術(shù)后皮膚缺損乳腺癌根治術(shù)后自體組織乳房重建保乳術(shù)后局部畸形放療后胸壁潰瘍,禁忌癥開胸術(shù)后背闊肌被切斷胸背血管受損者上胸壁大面積皮膚缺損者,.,背闊肌的解剖學(xué)基礎(chǔ),.,背闊肌解剖學(xué),位于肩胛骨下方，三角形發(fā)于T7T12、腰骶椎和最下面34根肋骨，止于肱骨結(jié)節(jié)間溝供血來源于胸背動(dòng)脈和內(nèi)乳動(dòng)脈及肋間動(dòng)脈的穿支神經(jīng)支配為胸背神經(jīng)功能：使肱骨內(nèi)旋，上臂的內(nèi)收和外展,.,背闊肌肌皮瓣的應(yīng)用,歷史：Baudet (1976) 首先進(jìn)行了游離移植的報(bào)道。以后臨床廣泛應(yīng)用，成為最常用的游離皮瓣之一 皮瓣特點(diǎn)：血管分布恒定，蒂部管徑在1.52.0mm。血管蒂長：68cm易于剝離和切取供區(qū)范圍大：68cmX 1215cm供區(qū)不遺留明顯的功能障礙皮瓣血運(yùn)豐富可形成單純的肌瓣可用于進(jìn)行肌肉功能的重建 應(yīng)用范圍：帶蒂移植：胸部、上肢的組織缺損，屈肘功能重建，乳房再造等游離移植：頭、面、頸、四肢、軀干等部位均可應(yīng)用,.,1,術(shù)前先描畫出手術(shù)切口全麻下，先仰臥位，行乳腺癌改良根治或根治術(shù)乳房切口徹底止血后用濕大紗布覆蓋并用無菌手術(shù)膜隔離,.,2,再取側(cè)臥位，在背闊肌表面按預(yù)先設(shè)計(jì)的梭形切口逐層切開沿背闊肌前緣切取背闊肌并向后方延續(xù)，注意保護(hù)前鋸肌及大圓肌注意保護(hù)血管蒂把肌皮瓣經(jīng)皮下隧道輕送到乳房創(chuàng)面,.,3,再改為仰臥位，將轉(zhuǎn)移的肌皮瓣縫合固定于前胸壁切口并關(guān)閉皮膚切口切口輕度加壓包扎引流管負(fù)壓吸引,.,手術(shù)技巧及注意事項(xiàng),.,1.體位,1.先仰臥位；2.側(cè)臥位；3.最后仰臥位,.,2.保護(hù)胸背血管蒂,胸背血管,胸外側(cè)血管,.,5.慎防誤切大圓肌及前鋸肌,誤切上述二肌肉會(huì)引起肩關(guān)節(jié)內(nèi)收功能障礙,.,臨床體會(huì),.,